12 June 2017

Why are doctors killing themselves?

DOCTORS are generally acknowledged to be intelligent. We are trained to care for the human body, and we are considered to be the experts on it and how to take care of it. And we care deeply about people and would never knowingly harm them. Indeed, our Hippocratic oath says to “First, do no harm”.

So, why are doctors killing themselves?

The statistics are shocking. Rates of suicide among doctors are quoted as being up to 3.4 times higher than the general population for men and up to 5.7 times higher for women. A meta-analysis in 2004 found lower numbers than this, at 1.41 for men, and 2.27 for women, but whatever the numbers, the rates are higher than normal, not lower. And these are the numbers we know about. There is such a stigma and shame around suicide that we usually don’t acknowledge this as the cause of death, and obituaries use euphemisms such as “died suddenly”, “taken from us too early”, “in tragic circumstances”, “passed away sadly and unexpectedly”, so the rates are probably higher than this.

This is an indictment of our noble profession; that those who have made it their life’s work to care for others, seem unable to care for themselves, even to the point of not being able to keep themselves alive. How on earth has this come to be?

In other professions, if one work-related death occurs, everything stops until the cause is found and rectified, without blaming or shaming any one individual. In medicine, it is now regarded as so “normal” that some of us will become so exhausted, depressed and defeated that we will kill ourselves, that it is delivered in student lectures as just another list of statistics you have to learn and regurgitate if you want to pass your exams. No attempt has been made to see it as anything other than a personal failing or weakness, an inability to have “what it takes”.

We need to ask: why are doctors committing suicide? Why do we even describe it that way? We commit crimes, not suicide. Why do we become so desperate that we see no other option than to take our own lives, in complete violation of everything we stand for?

Perhaps we could also ask: why does it not happen more often? Suicides are but the tip of the iceberg of the exhaustion, anxiety, depression, burnout and hopelessness that is plaguing modern medicine.

Doctors are not superhuman

We seem to have become used to seeing doctors as superhuman – as capable of doing without food, drink, sleep and a normal human social life for long periods of time; as not being affected by human misery and suffering, and the gamut of emotions people go through in the face of illness and disease, that they have to deal with every day – as if we were naturally imbued with these qualities or we have been somehow trained to develop them. But is all that true? The trouble with the “doctor as superhero” image is that when we falter and fail, as humans do, we are somehow blamed for this as a personal weakness, told that we weren’t up to the job. Nobody stops to see if the system we are working in has some part to play.

For doctors are people too – normal, kind, caring, people, with all the weaknesses and great strengths that other people have, no more, no less – and yet, we are treating them as less, and expecting them to be more.

Why do we:

Not have rules that regulate the number of hours we can work before we have to take a break?

Assume that they are guilty if someone else blames them for something?

The normal rules of Occupational Health & Safety, the Law, and common sense, are not applied to us.

The culture of medicine is cruel:

the selection process favours mental activity at the expense of all else, including the body we are supposed to be learning to care for;

the system of training fosters competition over collaboration and focuses on the passing of exams via the regurgitation of learned knowledge, rather than the development of people who will practice the art and science of true medicine;

the way we are worked is in complete disregard of our own health, wellbeing and lives;

we are treated as expendable pawns in a system that preserves itself at all costs;

the way we are with each other is competitive and harsh, rather than open, honest and supportive.

And, if we are struggling and would like to seek help, the normal rules do not apply here either. If a “normal” person comes to see us professionally, we are bound to protect their confidence, so that they can in fact have confidence in us and know that they can seek help without fear of consequences.

Yet, if a fellow doctor comes to see us, and we deem that they are “impaired” in some way, we are obliged to report them to a governing body that we know will treat them as if they are guilty of a major criminal offence, will possibly strip them of their right to practise medicine, and will place humiliating conditions on their practice if they are allowed to continue, including exposing them to trial by media.

Is it any wonder that doctors are not seeking formal help, but hiding the fact that they are struggling, and are self-diagnosing and self-medicating, often compounding their original problems, and in fact putting themselves and the public at greater risk than if non-punitive, confidential help was still available.

There is such a shame and stigma around doctors being ill. Sickness is somehow seen as a personal failing and a betrayal of our colleagues. We feel unable to call in sick at work, even when we know we are posing a health risk to others, if we are contagious, or just temporarily incapable of doing our work and at increased risk of making an error. We would never insist that “normal” people work under these conditions, yet we push ourselves to show up at work, no matter how ill we are feeling.

We work in a system that increasingly holds the doctor responsible for everything. We, as a society, are becoming more irresponsible, and we, as individuals, are becoming more irresponsible. We think that we have the right to eat, drink, and otherwise live as we please, and when the inevitable consequences occur, as in the 90-95% of cancers that are lifestyle related, we think that we have the right to go to the doctor and ask to be fixed at once, and if they cannot, or if we experience side-effects of the treatment, we think that we have the right to blame the doctor personally for this, and to complain about them officially or sue them.

Conventional medicine so obviously does not have all the answers, as shown by our rising rates of illness and disease, and our inability to deal with the increasing complexity of multi-symptomatic and multi-systematic chronic disease these days. Yet if we dare to offer lifestyle advice to our patients, we will be censured, as was Dr Gary Fettke, even though we consider this part of our duty of care as doctors, and even though the evidence shows that the vast majority of chronic disease is lifestyle related.

Is it any wonder?

Is it any wonder, with all these pressures and stresses, that doctors’ rates of mental ill-health – of anxiety, depression, exhaustion, burnout and suicidality – are greater than those of the average person? And is it any wonder that when we cannot take it anymore, doctors think that the simplest solution is to kill themselves?

At that point, we have no understanding of the human carnage we are leaving behind.

If taking a day off work is such a disaster, what is the cost of taking a life?

If we care about our patients so deeply, do we consider the impact this will have on them; that the person they trust with their health, their life, cannot take care of their own? What example does this set for our patients? Does this cause some of them to give up on life too, if even their doctor cannot cope?

And how will our family and friends feel? Thinking that they will be better off without us is a lie that is fed to us, to make us feel better about what we are planning to do.

We leave in our wake an enormous amount of sadness and suffering, which is surely not intentional, for people who promised to “First, do no harm”.

“First, do no harm” starts with us

If we truly care about people, this has to include ourselves and our colleagues. “First, do no harm” starts with us.

We have to learn to appreciate ourselves, just as we are, without expecting ourselves to be perfect. We must care deeply for ourselves, so that we build a healthy body that can work in a diseased system, so that we don’t take the pressures of the job so personally. We must stand up for ourselves and each other in the face of a system that asks us to work at our own expense, so that we don’t feel personally devastated if we do make a mistake or if someone tries to blame us for their own lack of responsibility.

And if we are thinking of doing ourselves harm, we have to be able to seek help, without fear of recrimination or retribution, before it is too late.

I have lost two dear friends and colleagues to suicide. This is not a life experience I would wish on anyone. Two beautiful, bright, deeply caring, funny, tender, loving people, who were adored by friends, family, colleagues and patients alike. Two people dead, way before their time. And I have known other colleagues who have “died suddenly” at home or in car “accidents” which may well have been deliberate too.

It is time we all came together to deal with this problem of doctor suicides, bringing it out into the open as has been done most courageously in recent times by the families left behind, and dealing with it, without shame or stigma. We need to stand together and call out the abusive nature of the system we are working in, and our part in allowing it to continue, and start making changes in the way we treat ourselves, supporting ourselves and each other, which will lead to true and lasting changes in the system, from within.

What can we do?

We cannot change the culture and the systems of medicine overnight, although we certainly need to work together to effect true change, which is long overdue.

We can change the way we are with ourselves and each other.

Medicine as a culture has become uncaring, but we are not.

We went into medicine because we care deeply about people. But somewhere along the way, we forgot to (or were trained not to) care for ourselves. How can we possibly care for others if we are not first caring for ourselves? We have a duty of care for ourselves. “Do no harm” applies to us, first and foremost.

In medicine, as in life, we serve as role models. As parents, we model behaviours that our children tend to adopt, even when we tell them not to. And the same goes for our patients. We can say what we like, but are we living in a way that truly models good health for them? Are we eating well, exercising regularly, sleeping soundly? Are we full of vitality and joy? Do we love our work? Do we love being with people? They can see and feel all of this, and will either be inspired by us, to live in a more caring way themselves, or see that if even we cannot live well, how can they possibly hope to do so.

We have a duty of care for our patients by living lives that inspire them.

And we have a duty of care for each other, to keep an eye out for each other, to notice that someone is struggling, to reach out and help them, to bring them back into the fold. To care for them and truly support them, not condemn and isolate them.

For far too long now, we have allowed ourselves to be pitted against each other. The competitive nature of us as individuals has allowed “the system” to drive a wedge between us, to keep us divided so that we do not stand together for true change.

Doctors as a unified group are a powerful force for change, and this is known. Great effort goes into keeping us separate and small, for we could make a huge difference to our communities, our systems and the world if we stood united and strong.

It is time that we started to truly care, for ourselves and for each other, and to stand together, as one, for true change.

Dr Anne Malatt is an ophthalmologist who works in Bangalow, northern NSW.

If this article has raised issues for you, help is available at:

Doctors’ Health Advisory Service:

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Queensland … 07 3833 4352

Tasmania and Victoria … 03 9495 6011

WA … 08 9321 3098

New Zealand … 0800 471 2654

Lifeline on 13 11 14

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Poll

I have lost at least one colleague to suicide

32 thoughts on “Why are doctors killing themselves?”

one of the main problems doctors have is when an adverse event occurs rather than fully disclose the truth they are forced to take advise from their insurers lawyers. I believe most doctors would benefit from telling the truth. If the truth was told right from the start the burden of guilt would be removed and that would have to benefit both parties. No person should be advised not to tell the truth , this needs to change

We need a supervision system for our young doctors same as the psychologists have where a trained psychologist leads a debriefing 1 on 1 covering any difficulties, work or personal, difficult interactions, communication, professional skills and any adverse events. This person would then be well placed to promote wellness behaviors and watch for any mental health issues. Having everyone involved may circumvent the issue with doctors believing that they may put their career at risk by seeking support from psychologists or counseling

Any adverse event at any level be it a medical student or the top consultant in private or in public practice should have DEBRIEFING facility at the point where it happens with full DISCLOSURE and DOCUMENTATION of facts and reassurance with no guilt feeling and guidance to improve at all levels will help everyone concerned

This is an excellent article and brings up some very important issues. Many doctors are perfectionists and have trouble coping with their own errors, even blaming themselves when they had no control over an adverse outcome. In my 40 years in medicine there have been 15 medical suicides amongst my acquaintances and colleagues. This is way above the experience of the general community. Anaesthetists are particularly at risk, partly because they have the expertise to give themselves a painless death. Also at high risk are psychiatrists and female GPs. Surgeons don’t commit suicide as a general rule, but may self- medicate with drugs ( younger surgeons) or alcohol ( older surgeons). To compound the problems colleagues can show a lack of support or even judgmental hostility. It was put to me once that doctors and nurses generally are kind to their patients but can be very cruel to colleagues and I have found this to be true. . Attempts at support networks for troubled doctors have been of limited success as, by their nature, doctors have trouble asking for help, which they may see as showing weakness. Mandatory reporting compounds the tendency to avoid seeking medical help. This is a very fertile are for further study by medical associations and medical boards.

Thank you Anne for your passionate call to us all. As a psychiatrist, I am not sure how much workplace conditions contribute to suicide. My own experience, not just directly, but talking to colleagues who have lost friends to suicide, is that many of those colleagues who suicide have suffered either a severe episode of psychiatric illness, or suffer severe episodic or ongoing psychiatric illness. I have a different spin on workplace conditions. We are one of the last groups in modern society to accept Dickensian workplace conditions – we will continue to do so as long as we do not speak up. We should desire to improve our workplace conditions because, if we are trained to be bullies, that will be our culture – and we are likely to act in that way towards our patients – destroying our profession in the process.

Many doctors share the stigmatised community view of psychiatry and psychiatric illness. They do not seem to see my view of how, in a close collaborative therapeutic relationship, doctors can recover from or manage quite severe illness, so they can work, and do not have to encounter the medical board. Early identification and expert treatment of such disorders often does not occur, contributing again to the view that psychiatric illness is shocking to get. I think one of the most helpful interventions might be to introduce mandated (maybe via accreditation, as in Canada) return to work programmes for doctors and nurses in all medium to large health facilities. It is often difficult for doctors to find a return to work pathway, except for the altruism of some colleagues. Other doctors seeing their colleagues return to work after illness (mental and physical) might produce another view of illness in at least some of us.

Having witnessed first-hand the impact of malicious reporting (ie. my colleague was suspended based on stories made up by a disgruntled colleague and her friend despite 3 psychiatric reports clearing him) The case has only just begun and he has been forced to fork out over $250,000 while the colleagues even refused to give testimony later on and denied saying certain things.

If this case is so hard with someone who is psychologically fit to practice, and who has hard evidence that what his colleagues said was made up, then you can only imagine what would happen if he DID show signs of psychological illness.

It is certainly important to draw attention to this situation. I believe it is far more complex than improving work place conditions. attitudes to mistakes, developing a collegiate atmosphere and making help seeking judgement free. It really needs extensive research to try to determine what is really behind the resort to suicide to deal with physicians problems
Of course one suicide is one too many. Could it be that the figures for doctors are distorted because they are better at it?

I was at a meeting and I am not sure what the topic of the day was .For some reason the question popped up.
How many of us had a good night sleep. Out of 15 of us mostly men only 2 of us had a good night sleep.
We should address sleep at all times and follow through not giving excuses to ourselves.

There is compelling evidence that widespread bullying by disgruntled patients / colleagues, medical regulators (AHPRA), medicolegal lawyers and MDOs are mentally ‘gang-raping’ vulnerable individual doctors to the brink of mental breakdown and suicide. This is gross violation of our civil rights and all of us should voice out: ‘enough is enough’. It is time an independent taskforce is required to apprehend these perpetrators and serve us justice against professional abuse.

For a long time psychiatry has looked down on from within the medical profession, with medical students and junior doctors exposed to negative remarks ranging from the field being low paying to being only for inferior doctors who couldn’t make the cut elsewhere.

As such, it should come as absolutely no surprise that doctors are reluctant to access psychiatric and mental health services due to the associated stigma. If you have ever found yourself criticising your psychiatric colleagues with peers or juniors, then you need to ask yourself if you have also contributed to the problem.

thank you Anne for your very timely article. you raise 2 issues that will need to be dealt with now or otherwise it will be really forgotten by tomorrow with some more important ‘outbreak of zika etc’.
Firstly, the AMA and our Colleges should be beating down the doors of ministerial offices to reverse the AHPRA mandatory reporting, as this will improve our ability to seek help if we feel we need to. this in turn will improve health outcomes for doctors and their families, but also for patients in the longterm.
the other issue is the one about hours of work – yes we are by default type A personalities, who have also been trained to be workoholic. but, this is where safety and OH&S comes in to place. how come the junior doctors actually have safe hours of work. consultants and trained GPs have been forgotten about the need to improve our safety. we can be oncall, up with call and patients, yet we need to present next day to continue with clinics, and theatre work in terms of surgeons. this needs to stop, and to improve this, needs to be done via the political / union sphere. the nurses have put us to shame on this issue.
so again, your call is timely, and yet, we either go successfully to improve our lot as a united group, or we will keep on dying prematurely as a divided force.

Medical School culture is ready for a change.
Intelligence must be nurtured, supported and trained to care for it’s owner.
Buddies formed within mutual respect will enhance the carer within.
It must begin in first year and then carried forward until it’s no longer needed, even for the duration of a career.
We’ve talked about it.
We must do it.
Now….is already too late for some..

Bill talks of the social stigma of a diagnosis of mental illness.
There’s a story behind this
Those whom study psychology, psychiatry and philosophy know of the complexity of the human mind, and how the individual may be blind to solutions because of a lack of objectivity.
Here is the crux of the matter.
Just as we doctors care for the ill and vulnerable, we become imbued with a sense of human vulnerability.
We know all too well how flimsy might be our existence.
We know how to end life.
When the dreams that sustain us shatter under criticism and failure, there’s appears to be no one there to care for us, and we are so used to “coping”.
The very thing we need, escapes us in that moment of interminable disappointment.
We fall away from our own esteem and are crushed by the weight of our loneliness.

Thank you for such an important article Anne
When I was sued in the 1990s I wrote a similar article for our college journal…I had over 70 letters in response with more than half stating that in the same circumstances they had gross feelings of inadequacy, feelings of letting the person suing them down and in 20 cases suicidal thoughts.
A start would be to ensure that any colleague being sued is currently checked by friends and workmates.Making time to allow feelings to be discussed is invaluable.Caring for each other is as important as caring for our patients.
We have learned from the aviation industry about check lists prior to surgery.We need also to learn from them the absolute down side to fatigue in performance and steps taken to obviate this.Hours on call should be a start.
How to avoid? In my own case,exercise was the key.Better for the brain than the body.
But anything that takes us away from the day to day pressures must be good.
All of this needs to be discussed at medical student and junior doctor level.Let’s not be judgemental.Or alternatively let’s applaud those who get it right and provide leadership in this area through example.

Being currently in this space psychologically after a marriage breakdown & having lost three colleagues in the last 12 months to suicide I can categorically say the stigma of asking for psychiatric help in Medicine is probably almost as severe as I know it is amongst Army Colleagues from my ex-Army brother in-law. Until Medicine embraces mental ill-health as as real an injury as a Cholecystectomy, Appendicectomy or Musculoskeletal injury then few of us will seek help. I plan to get help 100’s of kilometres from my workplace due to stigma & concerns about confidentiality & the looming notification to AHPRA is like the sword of Damocles.

Wellness initiatives aren’t worthwhile if people are still dying and we keep saying we couldn’t have seen that coming.
It’s like teaching defensive driving when no one is wearing seat belts & the roads are a death trap.
Ask a colleague if they are OK & follow up – check in – tell them you’re worried to leave them on their own, drop in unannounced, it’s too easy to make a token comment & say “You know I’m here for you” – stand on the edge with me and hold my hand

I am a doctor from India and your article resonated with a large number of my personal experiences. Medicine is joy. We work with people at their most despondent, giving from our own energy and stock of joy to make an improvement in their lives no matter how minute. In India, the doctor is a Man of God and this paradigm is at the core at the fall of grace we are experiencing in the Indian subcontinent. Gods dethroned have further to fall than men and land harder. Our patients, our educational institutions, our superintendents and our councils and regulating bodies need to see as as human and treat us the same, we need to stop driving ourselves too hard and fast into the abyss and we need to step back and spend a moment wondering if we are happy with the way we are expected to do our jobs.

I recall as a student being intimidated most of the time by the pressure to perform. The question always in my mind whether I was studying the right course. I still remember the Professor of Surgery who gently nurtured my knowledge and encouraged me. I recall as an intern, learning that I was in the right vocation and that I did it well. I remember the physicians who rewarded good clinical skills from whom I learnt much. Prince Henry Hospital (Sydney) had a cafeteria that overlooked the golf course and the sea and lunch was at a table of colleagues, VMOs, nurses, allied health & administrators and the ambience and collegiality embraced us as if in an extended family. That hospital no longer exists and it seems that my early positive experience as a junior doctor also has been lost. Perhaps those experiences have given me a resilience that is denied those in hospital training now for whom it must seem like servitude. Its time for the reversal of mandatory reporting by the treating doctor because its time to return the rights of the Declaration of Geneva to the unwell individuals in our profession. There is a pervasive and systematic devaluation of health and the worth of the medical profession. Whilst its important to look inwards at how we interact and support our colleagues its also necessary to review and reform the system in which we operate.

A well written reasoned piece Anne: thank you.
My first observation of this issue is – my goodness how far we have come – being free and able to express this about suicide, identity potential causes and suggest the many means to achieve a remedy – some would say cure this malaise. Working with now engaged and vocal effected families, there is hope!
The next observation is that fear of revelation and possible rebuke and retrubtion still confounds: in media or in the workplace. The fear is all pervasive and we cannot change the culture in which we participate and so our champions have to rekindle, awaken and garner that pioneer spirit that saw us take up the ‘caring’ profession – which is noble. It should not be necessary to be ‘anonymous’ or expect ‘whistleblower’ protection for daring to speak ones mind. Rather like freedom of the press, the right to question and debate should be sacrosanct. We can agree and disagree we to move on.

We need to re-affirm that the Declaration of Human Rights does indeed apply to our medical profession – our colleagues, you and I. The legal rights extinguished in many ‘para-legal’ processes are degrading, inhumane, brutal and plain wrong.
The workplace of today is vastly different to that or 10 and certainly 30 years ago. The systems sadly are as cumbersome , inefficient and detremental to optimum care as ever.
We need to be allowed to treat the patient as we would expect to be treated and not suffer for it. If there is a problem it should be outed and fixed not swept under the carpet.
In the quest for perfection and to absolve organisations of responsibility and bar dissent, the clinician far too easily and too often becomes the scapegoat in bloated unresponsive systems.

The good news is all this activity, particularly the last month, sees a huge cadre of doctors expressing their feelings and clamouring for change, with significant support from policy makers and opinion leaders. This article helps. We are not ‘there’ yet, but we’re moving the agenda. Let’s not stop!

A system which encourages patients to complain if you don’t give them everything they want and a regulator who complains when you do leaves nowhere to hide. AHPRA and its government masters have much to answer for

Thank you Anne for raising this issue. It’s something I’ve thought about for some time. I write a novel, Dissection, published in 2008, that incorporated many of the ideas you’ve touched on in this article: our quest for perfection, our high expectations of ourselves, our unwillingness to seek help for personal suffering, our fear of doing harm to our patients. These traits, while usually encouraging us to do our best work, turn against us when things go wrong. I’m especially concerned that young medical graduates are suffering as much as any of us, given that we’re now talking more openly about these issues.

Is AMA running a campaign against medical bullying to save our vulnerable doctors from mental suffering due to our dysfunctional healthcare system? I saw 4 Corners addressing this issue and HPARA spoke out on this too. HPARA even held a conference focusing on this. There was a senate enquiry and recommendations made but we’re seeing enough effective improvement. Medical Board chief spoke about zero tolerance to bullying but what does she really mean? And we have large MDO making big advertisement about how they can ‘help’ us but then hear news how their members were forced to eat humble pie when they faced medicolegal problems and regulators’ action.
Joe Kosterich’s comment is very true.

Thank you Anne for this important and insightful article. In my view, we over-estimate the effects of working hours and physical fatigue, and under-emphasise the effects of expectations, fear of error, and blame.

It seems to me that these two influences have changed reciprocally over time. As a junior doctor, I recall much longer working hours but a much greater sense of workplace comeraderie, “we’re in this together”. As working hours have improved, vigilance over our work has increased, there is micro-management, time-pressure and close examination of every perceived error.

Certainly the quality and safety movement has improved patient care, but, if practiced poorly, it can lead to a culture of extreme fear, where tests are done and referrals made to “cover yourself” – not for objective patient safety but to avoid being blamed if something goes wrong.

We have an unrealistic “zero error” tolerance, which is impossible within a human system. Just like operative procedures have an expected complication rate, so do cognitive procedures.

In this toxic mix, add a group of providers who tend to be on the obsessive side, for whom making an error is personally devastating, and for whom respect of colleagues is highly valued.

In over thirty years of hospital practice, I have never been sued, but I have been ground down to despair many times by regulatory and investigatory processes initiated from within the system in a dumbed-down, simplistic, tick-box style of “governance”.

The requirements for mandatory reporting continue to be misrepresented. It would do everyone the world of good to re-read them and to encourage their colleagues to do the same. The bar is set very high, and the fears associated with mandatory reporting requirements are irrational.
Individual doctors and medical organisations need to represent the requirements accurately and counter irrational claims about the mis-perceived dangers of mandatory reporting.

Hear hear Anne. Beautiful and heart felt article. And hear hear Joe Kosterich: Yes reform of our system is required on many levels. We need to address all factors in health care that do not honour and respect the innate human rights and decencies of us all. And Sue Ieraci, I hear what you are saying about the ‘zero tolerance’ for error culture. Error is not negligence and there is huge and ridiculous pressure on us all to be inhumanly perfect, when it is absolutely not possible. We ask our students and our doctors to be something that is not possible, and perpetually hold them to ransom if not ostracise them for human frailties and vulnerabilities. We don’t have a ‘one punch’ culture, but we have a ‘one mistake and you are out culture’ which places perpetual distress and stress on people in the profession and interferes with the way they are able to both practice and enjoy medicine, and indeed no doubt sleep which someone referred to in the comments above! I feel that we need to bring about a more caring approach to us all as people in the profession. It concerns me deeply to hear so many stories of so many people suffering in an in humane working environment. The true care our profession needs begins with each of us.

We hear many stories of medical bullying. We read comment to be more caring and less blaming. We hear the call for change or reform. But unless we have truly weeded out the problem of regulators’ heavy handedness and bullies’ influential powers within our healthcare system, the mental suffering of many individual doctors will persist forever…and the suicide toll will keep on rising.

Sometimes it’s not about the long hours or the fear of making a mistake or an inability or unwillingness to care for yourself.

Maybe you’re one of the many women who has experienced sexual abuse or sexual assault, an abusive relationship or personal violence. Maybe you struggle with mental health problems as a result of that. But you’re getting by. You’re looking after yourself, you’re getting good quality care, and you’ve found a job which is a good match for your skills and provides the perfect work-life balance. Work is your refuge.

Until it isn’t.

You encounter a colleague who continually makes sexual jokes – there’s always one of those. You tell him it makes you uncomfortable, ask him to tone it down. He starts to make jokes about bullying and harassment complaints, about being victimised himself. The sexual jokes don’t actually stop. Instead they get personal. Workplace injury? The perfect opportunity for a sexually suggestive remark. You seek advice, make complaints, the suggestion is made that maybe you’re just being too sensitive. Boys will be boys. So you choose: put up and shut up – or leave, lose income, lose social contact, lose confidence. You wonder whether any of this is worth it. Maybe you decide it isn’t.

Bullying and sexual harassment is not always about the big stuff, about overt verbal abuse or physical intimidation or sexual coercion. Sometimes it’s just small things that are the last straw. Considering the central role of informed consent in medical practice, the behaviour of some members of our profession is shady as f**k. Whatever your sense of humour or your own level of comfort, the right to claim that something is a “harmless bit of fun” ends the minute someone says it isn’t fun and asks for it to stop. Consent 101.

Irrespective of how we deal with the other pressures in medicine, treating our colleagues with kindness and respect would be a good start.

The work hours of junior doctors remain a significant factor in the stress and mental health of this group. A registrar, house officer or intern who regularly “clocks off” at the end of their rostered hours when there is still clinical work to be done is likely to receive very mediocre reports from their consultants, yet be hauled over the coals by a hospital administrator if they work on and then record this on their timesheet (thus generating paid overtime). However, leaving much uncompleted work for an incoming evening or night medical officer is not only unfair to your colleague, it may also impact negatively on patient care and clinical outcomes. I worked in 1991 as an SHO at a Qld public hospital where the pay office was under instructions not to pay overtime and to tell any junior medical staff who tried to claim overtime that they would not be re-employed at the end of the year if they persisted. I don’t think much has changed in 25 years. Being put in a lose-lose situation repeatedly in this way would have to generate stress and adversely impact on mental health, to say nothing of fatigue.

It was mentioned above that there were senate inquires into bullying and into mandatory reporting. As a training doctor, I had no idea they existed until after they were closed. I was never emailed for input and really wonder which people contributed to the senate inquires. I know the colleges all wrote letters with their views to the senate. However, the colleges are a large source of bullying themselves. Most of the bullying talks you get at hospitals are lip service at best. Sure you can get HR involved and you can go to counselling but there is little in the way to protect your career if you take that route. Contracts are yearly. There is no obligation for your site to renew your contract and really no obligation to make sure your training is adequate. Most docs just keep quiet as a result.

“colleagues, medical regulators (AHPRA), medicolegal lawyers and MDOs are mentally ‘gang-raping’ vulnerable individual doctors to the brink of mental breakdown and suicide” This is so true. AHPRA will not get involved when a training doctor has a complaint about their College. The AMA lawyers always say do not attempt to sue the college or fight them in any way. There is no system in place to investigate factors that lead to poor performance or mental health issues. There is no inquiry when a doctor fails out of a program. There is no

Registrar contracts are always for 1 year and can be used to get rid of anyone rocking the boat or as a source of bullying or threat for use when complaining about excessive work hours. As a result, there is no actual commitment by the employer or the college to help see any doctor through their training. This is used time and time again against doctors in the system. When you compare Australia against US and Canada, you see that the training programs have a much higher commitment to their docs once on a program. They will not fail to renew your contract because the front desk admin person complains you didn’t say please. The failure rates are significantly lower. By significant I mean less than 7% vs. 50% in some Australian programs.

I can remember the odd abusive patient but that had minimal lasting effect. The majority of my work related stress has been due to fellow colleagues, toxic administrative and college staff, excessive work hours and general work environment. I found this to cumulative and know that it has led to many cases of burnout. Until we start to fix these underlying issues, mental health problems and suicide will continue.